BREECH

PRESENTATION and DELIVERY

Sy, Icene Rose C.

JUNE 2013

buttocks of the fetus enter the pelvis before the head

Breech Presentation

3-4%
Breech Presentation

Factors predisposing to breech presentation

Gestational age Hydramnios high parity with uterine relaxation multiple fetuses Oligohydramnios Hydrocephaly Anencephaly previous breech delivery uterine anomalies placenta previa fundal placental implantation pelvic tumors

DIAGNOSIS

FRANK BREECH

COMPLETE BREECH

INCOMPLETE BREECH

Categories

ABDOMINAL EXAMINATION

L1 Hard, round, readily ballotable fetal head

L2 Back to be on one side of the abdomen and small parts on the other

L3 If not engaged, breech is movable above the pelvic inlet

L4 Firm breech to be beneath the symphisis

VAGINAL EXAMINATION
BREECH PRESENTATION
Anus, ischial tuberosities

FACE PRESENTATION
Mouth, malar prominence

Fingers encounter muscular resistance Firm, less yielding jaws with anus

Fingers maybe stained with meconium No stain on removal of fingers

Anus and ischial tuberosities lie in a straight line Mouth and malar prominence form a triangular shape

IMAGING TECHNIQUES

Sonography
Computed tomographic (CT) scanning Magnetic resonance (MR) imaging Radigraphic Pelvimetry

Can it be rectified to normal?

VERSION

External Cephalic Version

performed exclusively through the abdominal wall when a breech presentation is recognized prior to labor in a woman who has reached 36 weeks gestation Contraindications 1. Vaginal delivery is not an option 2. Placenta previa 3. Non-reassuring fetal status 4. Prior uterine incision (relative)

Complications Placental abruption, uterine rupture, hemorrhage, preterm labor

External Cephalic Version

A. Clockwise pressure is exerted against the fetal poles. B. Successful completion is noted by feeling the head above the symphysis during Leopold examination.

Mode of Breech Delivery

In 2000, researchers conducted a large, international multicenter randomized clinical trial comparing a policy of planned cesarean delivery with planned vaginal delivery (Term Breech Trial).

ACOG Committee Opinion July 2006

investigators noted that perinatal mortality, neonatal mortality, and serious neonatal morbidity were significantly lower among the planned cesarean delivery group compared with the planned vaginal delivery group (17/1,039 [1.6%] versus 52/1,039 [5%]), although there was no difference in maternal morbidity or mortality observed between the groups

ACOG Committee Opinion July 2006

American College of Obstetricians and Gynecologists (ACOG) recommends that the decision regarding mode of delivery should depend on the experience of the health care provider.

ACOG Committee Opinion July 2006

Cesarean delivery is commonly, but not exclusively, used in the following circumstances:

Recommendations for Delivery

Techniques for Breech Delivery

Labor Induction & Augmentation

In oxytocin-augmented labor, however, infant mortality rates were higher and Apgar scores were lower. Cesarean delivery is preferred to oxytocin induction or augmentation with a viable fetus. Amniotomy induction is suitable.

Management of Labor
rapid assessment should be made to establish the status of the membranes, labor and fetal condition necessary staff

Methods of Vaginal Delivery

1. Spontaneous breech delivery.
without any traction or manipulation other than support of the newborn.

2. Partial breech extraction.

delivered spontaneously as far as the umbilicus, but the remainder of the body is extracted or delivered with operator traction and assisted maneuvers, with or without maternal expulsive efforts.

3. Total breech extraction.

The entire body of the fetus is extracted by the obstetrician.

TOTAL BREECH EXTRACTION

Extraction of frank breech using fingers in groins.

Once the hips are delivered, each hip and knee is flexed to deliver them from the vagina.

TOTAL BREECH EXTRACTION

Frank breech decomposition using the Pinard maneuver. Two fingers are inserted along one extremity to the knee, which is then pushed away from the midline after spontaneous flexion. Traction is used to deliver a foot into the vagina.

DELIVERY OF THE ARMS

DELIVERY OF THE HEAD

MAURICEAU MANEUVER

A. flexion of the head is maintained by suprapubic pressure provided by an assistant. B. Pressure on the maxilla is applied simultaneously by the operator as upward and outward traction is exerted.

DELIVERY OF THE HEAD

MODIFIED PRAGUE MANEUVER

Used when the back of the fetus fails to rotate to the anterior.

DELIVERY OF THE HEAD

PIPER FORCEPS

A. The fetal body is held elevated using a warm towel and the left blade of forceps applied to the aftercoming head. B. The right blade is applied with the body still elevated. C. Forceps delivery of aftercoming head.

DELIVERY OF THE HEAD

PIPER FORCEPS

A. The fetal body is held elevated using a warm towel and the left blade of forceps applied to the aftercoming head. B. The right blade is applied with the body still elevated. C. Forceps delivery of aftercoming head.

Entrapment of the Aftercoming Head

1. Dhrssen incisions. 2 oclock, 10 o'clock, 6 oclock.

2. Zavanelli maneuvercesarean delivery after replacement of the fetus back into the uterus.

3. Symphysiotomy - widen the anterior pelvis.

Analgesia and Anesthesia

Continuous epidural analgesia

Analgesia for episiotomy and intravaginal manipulations that are needed for breech extraction usually can be accomplished with pudendal block and local infiltration of the perineum. If general anesthesia is required, it can be induced quickly with thiopental plus a muscle relaxant and maintained with nitrous oxide.

Maternal Morbidity
Genital tract lacerations Intrauterine maneuvers Rupture of the uterus lacerations of the cervix and vaginal walls extensions of the episiotomy and deep perineal tears increase the risk of infection Anesthesia uterine atony postpartum hemorrhage

PROGNOSIS

Perinatal Morbidity & Mortality

Fetal injuries Fracture of humerus and clavicle Fracture of femur Neonatal perineal tears Upper extremity paralysis (eg pressure on brachial plexus) Term Breech Fetus head entrapment, cerebral injury and intracranial hemorrhage, cord prolapse, and intrapartum asphyxia

PROGNOSIS